MINISTRY OF EDUCATION

APPLICATION FOR ADMISSION TO THE

NURSING ASSISTANT TRAINING PROGRAMME – 2022

Complete Application in BLOCK LETTERS

1. Name: ………………………………………………………………………………………………………………………………
Surname Maiden Name First Name Other(s)

2. Home Address:..............................................………………………………………………………………………………………

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3. Mailing Address:……………………………………………………………………………………………………………………

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4. Telephone Number: …………………………..……/ …………………..……………...…./ ……………………………………..

Home Mobile Email address

5. Date of Birth: …………/…………/………… Age: …………………

dd mth yr

6. Sex: Male Female

7. Marital Status: Single Divorced Widow Common-Law Union

Married Separated Widower

8. Nationality: ……………………………………………… ……………………………………………………………………….

9. Identification Number:…………………………………/………………………………………../……………………………….
ID Card Passport Driver's Permit

10. Employed: Yes No If yes, state Place of

Employment:...............................................Position:..........................................

If no, state Place of Previous Employment………………......................................................Position:…………………………..

11. Number of Children: ……………………………………. Age Range: .........................................................................................

12. Next of Kin: ………………………………………………Relationship: ..................................................................……………

Telephone No: ……………………………………………Email Address:…………………………………………………........

Residential Address: ……………………………………………………………………………………………………………...

13. Extra-Curricular Involvement:…………………………………………………………………………………………………….

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14 (a). Education

Institutions Date of Entry and Examinations Passed Certificates Obtained and

Leaving and Year Grades
15. Names of two (2) referees:

1. Name:………………………………………………….. 2. Name: ......................................................................

Address: ……………………………………………….. Address: ......................…………………....................

Occupation: ……………………………………………. Occupation: ................................................................

Telephone No:………………………………………….. Telephone No:..............................................................

Email Address:…………………………………………. Email Address:………………………………………..

16. Write a brief paragraph in your own handwriting outlining your reason(s) for applying for the Nursing Assistant
Training Programme.

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17. A COPY of each of the following documents must be attached to this form. DO NOT ATTACH ANY
ORIGINAL DOCUMENTS.
Electronic Birth Certificate & Affidavit (if applicable)
Marriage Certificate (if applicable)
Academic Certificates
Two (2) Testimonials (not older than six (6) months)
Certificate of Good Character (receipts will not be accepted)
Approval letter from the Regional Health Authority (if applicable)

Signature: ………………………………………………… Date: ……………………………………………………..

OFFICIAL USE ONLY

Checked by: ……………………………………… Reference Number: ...................................................................

Comments:

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MoE/22